When performing submuscular breast augmentation, it is essential to follow a plan that will result in an attractive, natural-looking augmented breast while minimizing the potential for complications. Here, I present my approach, which emphasizes shaping the pectoralis major muscle and adjusting the inframammary crease to optimally position the implant.

Preoperative markings

On the day of surgery, with the patient fully awake and either sitting or standing, mark the current location of the inframammary crease (IMC), then draw an oval pattern extending from the lateral sternal border to the anterior axillary line and from the inframammary crease to a point 2 cm below the clavicle (Figure 1, A).

A, Before surgery, the patient and surgeon agree on an approximate implant volume after the patient evaluates several sizes of gel-filled round breast implants in a trial bra while looking in a mirror. During the consultation, the patient watches a DVD or video of the surgeon discussing important aspects of the surgery, including risks and possible complications, while following the video with a detailed checklist/outline, which the patient will sign when all questions have been reviewed. Implant size selection is influenced by the size of the patient’s rib cage. Other factors of importance are the patient’s height and weight; size of shoulders, hips, and buttocks; and the aesthetic preferences of the patient and the surgeon. Typically, patients with a very small frame who wear a 32 inch trial bra receive an implant volume of 250 to 300 cc, patients with a 34 inch bra receive an implant volume of 275 to 350 cc, patients with a 36 inch bra receive an implant volume of 300 to 375 cc, and patients with a 38 inch bra receive an implant volume of 350 to 450 cc. B, In most cases, the existing IMC will have to be lowered to center the implant behind the nipple-areola complex. Otherwise, the breast implant will produce excessive upper-pole fullness and a downward-pointing nipple. Here, the nipple-IMC distance was increased from 6.5 to 9.0 cm to accommodate a 300-cc implant inflated to a total of 320 cc. A low profile round smooth implant with a diameter of 12.6 cm and a projection of 3.7 cm was used.

After the induction of general anesthesia using a laryingeal mask airway, but before skin preparation, mark the new or adjusted IMC. This location varies with implant size but is typically 9 cm from the center of the nipple when the nipple/areola is pulled gently upward between the nondominant thumb and index finger (Figure 1, B). This allows a 300- to 340-cc implant to be centered properly behind the nipple-areolar complex and avoids excessive upper-pole fullness. If you use an implant larger than 340 cc, measure the new IMC at 9.5 to 10.0 cm; if you use an implant smaller than 300 cc, measure the new IMC-to-nipple distance at 8.5 cm or less.

If you choose an inframammary incision, mark a 2.5-cm incision, 1.0 to 1.5 cm above the new (lower) IMC. If you use an areolar incision, extend it along the inferior areolar margin from 3 o’clock to 9 o’clock.

Implant selection

I prefer smooth, round implants to anatomically shaped implants because implant rotation is not an issue with smooth implants, and the appearance of smooth implants is similar to that of anatomically shaped imp-lants when placement is submuscular.

Virtually all of the implant deflation that I have seen occurs in patients with textured implants. More-over, I have observed a higher incidence of rippling/wrinkling and capsule contracture with textured implants. Smooth implants have greater mobility and assume a more natural motion when the patient walks or runs. Capsule-expansion exercises are more effective with smooth implants because the implants are mobile (not adherent to the capsule).

Technique

If one breast is clearly larger, operate first on the smaller side because the limiting factor is the maximal volume the smaller side can accommodate. Then size the larger breast to match the volume of the smaller breast. If you plan a unilateral mastopexy, position the implant first and customize the mastopexy to match the size and location of the areola of the smaller breast.

Choice of incision

I prefer an inframammary or periareolar incision to an axillary incision because these provide better visualization of the retromuscular space, particularly in the lateral portion of the dissection. This facilitates improved hemostasis and protection of intercostal sensory nerves. Moreover, I am better able to adjust the IMC with my fingertips and stretch out or obliterate the old IMC, even after the implant has been fully inflated.